The pattern and associations of 62 instances of external birth trauma (EBT) in 57 of 2222 consecutive hospital-born neonates were studied. Macrosomia and vaginal instrumental or breech delivery were identified as significant risk factors for EBT. In contrast to previous reports, subgaleal hemorrhage (SGH) was the predominant form of trauma (n = 33) and it was associated with vacuum application in 28 of 33 (85%) neonates. Brachial plexus palsy (BPP) (n = 10) occurred with the highest frequency (6.4%) after breech delivery. Fractures were uncommon. Multiple injuries (10 items in 5 babies) were mainly associated with vacuum extraction. The high rate of vacuum extraction (VE) and problems with its use including a high VE failure rate (30/242 = 12.4%) were considered contributory to the unusual pattern of EBT seen in the study. Regular audit of delivery practices, greater care in excluding cephalopelvic disproportion and judicious use of VE are recommended to reduce the morbidity from EBT.Between August 1986 and June 1987, 57 of 2222 (2.6%) newborns delivered at the General Hospital in Abha, the capital of Asir province in Saudi Arabia, suffered external birth trauma (EBT). 62 instances of EBT occurred to these 57 newborns. 5 newborns suffered multiple injuries. One newborn with multiple injuries was born spontaneously and weighed 4.58 kg. The types of EBT included subgaleal hemorrhage (53.2%), brachial plexus palsy (16.1%), cephal hematoma (14.5%), laceration (8.1%), facial palsy (4.8%), clavicular fracture (1.6%), and extensive bruising (1.6%). EBT occurred more often to infants who were born via assisted delivery than to those were delivered spontaneously (12.7% or vacuum extraction, 10.4% for forceps delivery, and 11.1% for breech delivery vs. 0.6%; p .05). When the researchers excluded the 4 babies who were ultimately delivered by cesarean section because of failed vacuum application, the EBT rate for cesarean section was just 0.9% compared to 2.65% otherwise. The EBT rate for failed vacuum extraction was rather high (30/242 [12.4%] applications). EBT newborns were significantly more likely to weigh more than those not suffering from EBT (3.3 kg vs. 3.01 kg; p 0.01). Subgaleal hemorrhage and brachial plexus palsy accounted for most of the association between birth weight and EBT. In fact, vacuum extraction was responsible for most (85%) of the subgaleal hemorrhage cases, some of whom were cephalopelvic disproportion (CPD) cases. These findings reveal a need for regular evaluations of providers obstetric/delivery practices to reduce EBT morbidity. They suggest that providers should more carefully assess CPD cases and use vacuum extraction more judiciously.